Please enable JavaScript in your browser to complete this form.Business Information - Step 1 of 4What state is your business located in? If you travel for work, pick the state your business is based in.What type of business do you want to insure? You may do more than one thing. For this, type in your main industry.Business nameBusiness AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBusiness WebsiteBusiness Start Date (approximate)What date did your business begin operating under the current ownership? MM/YYYYWhen would you like your business coverage to start?What is your gross annual revenue?These are your projections for the next 12 months. e.g., $400,000Please provide your projected estimates for the next 12 months. For owner only businesses, please enter your yearly salary as your payroll.Employees & PayrollPlease provide your projected estimates for the next 12 months. For owner only businesses, please enter your yearly salary as your payroll.OWNER/OFFICERS/PARTNERSNo of Owners with Total Annual PayrollFULL TIME EMPLOYEESNo of full time employees with total annual payrollPART TIME EMPLOYEESNo of part time employees with total annual payrollNextGeneral Liability Coverage QuestionsThese details will help us determine what coverage you need.Do you currently have a General Liability insurance policy in effect?NoYesHave you filed any insurance claims for this business in the past five years?NoYesDoes your business perform any design, construction, installation, removal, or physical repair of any property or tangible good?NoYesDo you or your business supply, manufacture, or distribute any tangible goods or products?NoYesDoes your business use rented or non-owned vehicles (e.g. an employee's car) for business purposes?NoYesDo you sell any products under your name or label or rebuild, rent, refurbish, install, repair or recycle any products?NoYesHas your business had any commercial insurance cancelled or rescinded?NoYesBased upon your knowledge and the knowledge of your business’s current and past partners, officers, directors and employees, during the last five years has a third party made a claim against your business or have a reason to make a claim?NoYesAre you a professional employer organization (PEO)?NoYesDo you provide temporary staffing?NoYesPreviousNextProfessional Liability Coverage QuestionsThese details will help us determine what coverage you need.Do you currently have a Professional Liability insurance policy in effect?NoYesHave you or anyone associated with your business ever been the subject of a professional disciplinary action within the past five years?NoYesProjected annual gross sales from largest client or projectThis is the largest sum of money you've received from a single client or project. e.g., $40,000Does your business use a written consent form or statement of work?AlwaysMost of the timeSometimesNeverIf required by state law, does your firm maintain current and valid professional training, certifications, licenses or designations for all services you provide?YesNoDo you maintain current and valid professional certifications or designations as required or recognized by industry standards?YesNoDoes your business do any of the following?Act as a Professional Employer Organization (PEO) Lease employees or provide employees on secondment to other organizationsPerform any recruiting activities for medical personnel, including but not limited to nurses, doctors, dentists, etc.None of the aboveWhat type of jobs are primarily placed and/or recruited by your business?Do you conduct background checks on your applicants prior to placement?AlwaysSometimesNeverDo you test and evaluate your applicants' skills and qualifications prior to placement?AlwaysSometimesNeverDo you perform and verify background checks and qualifications/credentials of all potential job candidates?YesNoHave you, your business's current and past partners, officers, directors, board members, trustees, or employees, been subject to disciplinary action by authorities as a result of professional activities?NoYesPreviousNextWorkers Compensation Coverage QuestionsThese details will help us determine what coverage you need.Please list all owners or officers [Full Name with Ownership percentage]Please list all owners or officers Enter owners and/or officers and indicate if that person will be added to the policy. Businesses that do not have employees added to the policy must add at least one owner or officer.Do you currently have a Workers Compensation insurance policy in effect?NoYesHow many years of management experience does your management team have in this industry?e.g., 5What is the compensation arrangement for your staffing services?Client pays us the worker's salary plus commission and then we pay the workerClient pays the worker's salary directlyArrangement varies by client Do you provide any staffing services for the construction industry?YesNoDo you provide any staffing services for the farming or landscaping industry?YesNoHave you had any workers compensation claims for lost time or medical in the past three years?NoYesDo you use any volunteers or donated labor?YesNoPreviousSubmit
